Hillary Clinton, then US secretary of state, visits the Ngoc Lam pagoda, which receives funding from the US President's Emergency Plan for AIDS Relief (PEPFAR), in Hanoi, Vietnam, in 2010. Photo credit: Bloomberg

A pharmacy of Cho Ray, a major Ho Chi Minh City-based hospital, was packed on a recent Tuesday afternoon.

The crowd, mostly poor people from southern provinces (many clad in pajamas), looked around nervously as pharmacists in white coats shouted their names and totals over a loudspeaker.

Some had to pay as little as VND78,000 (less than $4) and others as much as VND2 million ($94).

The poorest among them scoured their pockets and bags for change, turned to the relatives standing next to them or began making telephone calls in search of a loan.

“My bill is VND266,000, which is already a big headache given that I have to take a bus here every month,” said Nguyen Van Tien, a shrimp farmer in an outlying district in the Mekong Delta province of Ben Tre, where quality medical care is more or less non-existent.

Tien said his ability to pay for the treatment for a benign bladder tumor remains as uncertain as the weather.

“I don’t know what will happen if the treatment drags on and the medicine prices go up,” he said.

Critics of the Trans-Pacific Partnership (TPP) treaty say people like Tien have a lot to worry about.

The 12-nation, US-led trade deal has been negotiated in secret for years, leaving many to guess what it may contain.

However, last November WikiLeaks published a document described as a draft chapter of the agreement that sparked outrage among public health advocates.

‘Upbeat over the progress’

Many interpreted the leak as evidence that the US hopes to secure greater international price controls for pharmaceutical companies, threatening patient access to affordable treatment, particularly in developing countries like Vietnam, where the average person earns less than $15 a day.

According to the Wikileaks draft, Vietnam objected to that particular proposal.

But the document is now more than a year old and few in the world know what, if anything, has changed in the interim.

Higher-level negotiations on such matters are expected this month.

By and large, however, ranking Vietnamese officials in Hanoi have expressed high hopes for the TPP, which some believe will provide leverage against China's outsized economic influence.

“There has been some headway made on the TPP negotiations,” Tran Quoc Khanh, deputy minister of Industry and Trade and Vietnam’s chief negotiator, told the media after 12-nation talks wrapped up in Hanoi last month.

“We’re upbeat over the progress of the negotiations and there remains a possibility that the pact will conclude successfully.”

Profits trump health

Public health advocates maintain that the US is seeking to extend and strengthen existing monopolies on medicines, and restrict the ability of foreign governments to ensure affordable drug prices.

Such provisions, they say, would delay market entry of generic equivalents of patented medicines, which in turn would raise the cost of medicines and thereby increase private and public spending on them.

According to the leaked text, the US is also pushing for 20-year patent protections in certain areas related to public health.

World Trade Organization rules, on which all TPP countries' intellectual property standards are based, do not require such protections.

“The US claims to promote human rights and dignity yet promotes profits over life. Such a policy cannot be justified. It is done for the benefit of the all-powerful pharmaceuticals,” Dennis McCornac, a professor of economics at Loyola University in Baltimore (Maryland), told Thanh Nien News.

McCornac said this wouldn't be the first time vested interests had been packaged as public interests.

But to claim such a pursuit is mutually beneficial when its impact on different members remains uncertain, is probably a bit too “disingenuous.”

“At a time when globalization is blamed for growing inequalities within and across countries, policies seen as transferring enormous resources from consumers in poor countries to a few pharmaceutical multinationals, for example, will certainly face opposition,” he said.

Another country heard from

Some have dismissed such claims as anti-trade claptrap.

“I don't see how the TPP will necessarily have harmful impacts on human life,” said Deborah Elms, executive director of the Asian Trade Center in Singapore. “I suspect that most Vietnamese consumers and patients will actually be better off after the TPP goes into effect.”

Elms said that if the government can follow through, medicine should become more widely available and perhaps even cheaper as the TPP begins to allow the importation of more drugs.

“And the quality ought to be improved, since illegal, dangerous substances masquerading as genuine products should no longer be available. All of this should lead to improved patient outcomes, rather than worse situations.”

Aside from free-market faithful, many in the pro-TPP camp see the pact as key to ensuring the US will continue to write the rules for trade in the Asia-Pacific region and stay central to the global economy at a time when many are organizing their manufacturing, agriculture and service sectors around China.

The TPP would create a free-trade zone from Australia to Peru with $28 trillion in economic output, or 39 percent of the global total, according to a recent Bloomberg report. The countries in the pact are the US, Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore and Vietnam.

"One of the things that we want to try to conclude is the Trans-Pacific Partnership trade agreement, and Vietnam is working very hard with us in order to be able to do that," US Secretary of State John Kerry said Thursday after meeting Vietnamese Deputy Prime Minister and Foreign Minister Pham Binh Minh, who wrapped up his two-day visit to the US on that day.

A man, center, raises his hand as he takes part in a protest against Trans-Pacific Partnership (TPP) trade talks outside the prime minister's official residence in Tokyo, Japan, in April 2014. Photo credit: Bloomberg

Crippling effect

But Oxfam, an international anti-poverty group, has warned that if these proposals materialize, they will have dire health consequences for millions of people across Asia and Latin America.

For a country like Vietnam, which already wrestles to keep up with high drug prices, the effect could be crippling.

According to a World Health Organization report, Vietnamese patients pay 46.58 times the international reference prices for innovator brands and 11.41 times the cost of the lowest-priced generics.

Many drugs for diseases like HIV/AIDS, cancer, and hepatitis B and C are already too expensive for most people here, Oxfam said.

Up to 170,000 Vietnamese still require basic treatment for HIV/AIDS and thousands more will soon need new, patented anti-retroviral medicines as they increasingly develop resistance to their current treatments.

The US proposal would increase the costs of these drugs too.

The problem could get worse as more than 90 percent of the country's HIV/AIDS-response funding comes from international donors, who plan to reduce or phase out projects due to the country's new middle-income status.

The US, which currently provides more than half of the country's HIV and AIDS treatment budget, plans to pull the plug in 2015.

According to the latest estimates, Vietnam is among the 12 countries in the world that account for more than 90 percent of people living with HIV.

“If Vietnam is required through the TPP to introduce excessive intellectual property protections that will expand the monopoly power of the pharmaceutical industry, this problem will only get worse and Vietnam will be deprived of policy tools that can be used by the government to promote generic competition and make new medicines more affordable,” said Stephanie Burgos, senior policy advisor for Oxfam America.

Food or medicine?

In the past decade the US has consistently demanded in trade negotiations that poor countries introduce measures that would increase medicine prices, activists say.

In Vietnam, where patients already pay 72 percent of their medicine costs, thousands more could be pushed into poverty, Oxfam warned.

“They will have to choose between medicines and other basic necessities, or forego treatment altogether,” Oxfam’s Burgos said.

During the recent visit to Cho Ray's pharmacy, a couple in ragged clothes waited nervously to purchase medicine for their son.

After glimpsing a bottle of water under the bench in front of her, the wife quickly grasped the bottle and poured some water into a small thermos she brought along.

Right after her husband finished paying the bill, she rushed him and her son out of the hospital so they could catch a bus back to their hometown in the Mekong Delta.

“Now we don’t need to buy any food for me,” she told her husband. “I already have water. I only need to drink.”